Navitus Health Solutions

I would like the names and phone numbers of the physicians on your pharmacy and therapeutics committee. I'm just curious as to whether any of them are actually practicing in my specialty, or if decisions about my patients health are being made by physicians/nurses/pharmacists who have no first-hand experience with the diseases I'm trying to treat and the medications that are most efficacious in my experience. I'm looking forward to a lively debate about their questionable decisions. Thanks much.

Review: I have made over 7 phone calls this February over the same issue- trying to get a medication covered that I have been on for years. In my first phone call regarding this issue, the Navitus representative said the doctor's office needs to fill out and fax the "Exception to Coverage" form. She said if they put that I've been on this medication for years, which I have, then they will most likely cover it. This medication is the only thing that has worked for me, in combination with a topical medication that I also use. To date, my doctor's office has faxed over the "Exception to Coverage" form on multiple occasions and even called and talked to someone at Navitus but to no avail. Each time I call to follow up, there is a new reason added as to why my medication can't be covered. They do not provide this information to my doctor's office. They just make up more excuses while on the phone with me, or they act completely clueless. I asked to speak to a so-called "clinical pharmacist" and got a person named Bibek, and he did not provide any information about medications to me. I specifically asked him what medication is on their formulary that is safer and more effective than the one they are denying coverage for, and he could not answer my question. Again, this is a "clinical pharmacist" who is supposed to know all about medications. His response was to tell me to go online and look at their formulary. The job of a "clinical pharmacist" is not to tell someone to go look online. He was unable to provide any medication names or any information about medications. I am appalled that such a person is a licensed pharmacist. Our conversation continued and he again could not name any medication that is safer or more appropriate for me and yet he wanted to play doctor and deny coverage for the medication I need (he could not provide any information about this medication either). He told me my doctor needs to fax over more information. My doctor's office had already faxed over the requested information on several occasions. He said they need to put how long I was on this medication and then it can be covered. They initially did this, but I called my doctor's office again and asked if they put that on the form, and they said yes, but they will fax it again in case it was "overlooked" the previous times. I called Navitus again to make sure they received it this time. The lady calls me back and says now they need a complete list of my allergies. This has nothing to do with the situation at hand, and I had already told them my allergies in previous conversations and my doctor's office had also written it on the forms they faxed over. They were not recommending medications I was allergic to, so I do not know why they were even requesting this information. I feel very uneasy with insurance companies and PBMs prying and asking for more information than what is necessary for them to do their jobs. This is illegal and a HIPAA violation. My allergies have nothing to do with this medication being covered, or the alternatives they may have on their formulary. I asked the Navitus lady why they need to know my allergies and she could not provide a valid reason. She said the clinical team said they need it. I also asked her why they are requesting information multiple times that have nothing to do with this claim and that me and my doctor's office have both provided to them on numerous occasions, and she could not give a valid reason. She again said the clinical team needs it. This last lady I spoke to was nice, but she was not the one who approves or denies claims, so there was only so much she could do. She was not a healthcare provider or pharmacist and yet she was more helpful than the Bibek "clinical pharmacist" because she at least named some of the other drugs on the formulary. She obviously could not tell me about the safety or effectiveness but Bibek gave me no medication names or medication information at all and he's a PHARMACIST! They do not put patients first. It's all about greed and money. They have no problem taking people's premiums, but the one time I need something covered, they are refusing to pay for it. They have never payed for anything for me. This is the first time I need something covered. I don't think it's too much to ask for them to cover one medication.Desired Settlement: I want Navitus to cover the cost of my current medication since my physician has determined I need it, and this is what has worked for me all these years. I also want them to not pry unnecessarily into people's medical histories and violate HIPAA laws by asking for more medical information than they need to perform their duties. I am concerned about where my medical information has ended up because my doctor's office has faxed them my information multiple times, and yet they don't see it or can't find it. I'm also concerned that I had to repeat my personal information to so many different people due to the high number of calls I have had to make regarding just this one issue. I would like a manager to listen to the phone call between me and the clinical pharmacist, Bibek, and see that he provided no clinical knowledge or services to me. I am concerned that this person is a healthcare professional.

Business

Response:

Khodaparasty Revdex.com Review: We have reviewed the above complaint, and Navitus Health Solutions (Navitus) understands the plan participant’s position. Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug benefits for its clients and their members. Our clients require that we implement a prescription benefit program that is safe, clinically appropriate and cost effective. A Pharmacy and Therapeutics (P&T) Committee, composed of independent physicians, nurses and pharmacists, makes decisions on which drugs are available for coverage and ensures that options are available for brand alternatives and generics. There may be certain categories of medications that are excluded from the prescription benefit plan. With regard to standards related to “minimum necessary” under HIPAA, Navitus is knowledgeable of these standards. While we understand that the member may be frustrated with questions about her healthcare, our practice is to ensure that all elements of any patient’s condition are taken into account when evaluating coverage of a medication for both the safety of the member and to ensure adherence to benefits. Navitus manages a clinical messaging system that includes information about members’ allergies to help prevent members being given drugs to which they are allergic. This system provides warning messages to pharmacies when they are processing a prescription the member may be allergic to, directing the pharmacist to double check the prescription in order to avoid the member suffering an allergic reaction. The use of this information is a patient safety function that clearly falls under the HIPAA exceptions for payment, treatment, and operations, and has helped to avoid life threatening reactions for Navitus’ members who were prescribed drugs to which they are allergic. While the member in this letter correctly identified that there was no connection between the request for approval of payment for the member’s preferred medication, there is nothing illegal about Navitus requesting information about the member’s allergies and using it to help improve the member’s safety with regard to future prescriptions when claims are processed. The member, of course, has the right not to provide the information if they so choose. With regard to safeguarding patient information under HIPAA, Navitus is aware of its responsibilities. We have confirmed account documentation of phone calls from the member as well as receipt of documentation from the provider. The information that Navitus has received has been appropriately tied to the member’s account to ensure its protection. Navitus has strong processes to monitor incoming documentation to prevent loss, compromise, or inappropriate handling. Navitus is currently addressing this matter with the participant and informing her of the appeal options that are available under her prescription benefit plan.

Consumer

Response:

Review: In a letter I received from Navitus dated February 26, I discovered that they would not cover and pay for a blood pressure medication that I have been taking for many years, and which has proven to be effective and documented as such by my doctor.

Navitus wants to put into place a so-called “step” process, where in I would try their recommended substitute medications in place of the one I am already taking, and which already has been proven to work. In my March 3 conversation with a Navitus pharmacist, I asked whether or not they could 100% guarantee that a substitute prescription would be as effective, and would not produce negative health results.

They were unable to provide this guarantee. That being the case, I asked them why they would choose to put my health at risk in trying a different prescription when it was already clearly documented that the prescription I am currently taking works without risk or detrimental health impact. When pressed, the pharmacist stated that it was a cost factor.

Given that Navitus is a multi –billion dollar enterprise with an extraordinary profit margin, this is a fatuous argument. Clearly, the only reasons for denying me covered access to a medication that has already proven to work, as opposed to a suggested medication that may or may not work, are greed and obstinacy, both of which have no place in patient care.

Further, in order for me to obtain a different prescription, I will have to see my doctor, which means I will have to pay for an appointment that I don’t need. This is a problem not of my making. At the very least, Navitus is guilty of putting their own needs ahead of those of the patient, and at the very most, they are guilty of violating the “do no harm” clause of the Hippocratic oath. In sum, this is playing Russian Roulette with my health.Desired Settlement: I want Navitus to allow and cover the cost of my current blood pressure medication. I want Navitus to reimburse me for the cost of my doctor's visit which is required in order to obtain a different blood pressure medication which, as stated, I do not need and would not need but for their insistence that I try medications which they cannot guarantee will work as effectively as that which I already take.

Business

Response:

We have reviewed the above complaint, and Navitus Health Solutions (Navitus) understands the plan participant’s position. Navitus is a pharmacy benefit manager with the mission to provide cost-effective prescription drug benefits for its clients and their members. Our clients require that we implement a prescription benefit program that is safe, clinically appropriate and cost-effective. A Pharmacy and Therapeutics (P&T) Committee, composed of independent physicians, nurses and pharmacists, makes decisions on which drugs are available for coverage and ensures that options are available for brand alternatives and generics. Navitus addressed this matter, in accordance with the benefit plan guidelines established by the plan sponsor, with a favorable outcome for the plan participant. [redacted]Senior Grievance and Appeals CoordinatorNavitus Health Solutions[redacted]

Consumer

Response:

Please be advised that my complaint lodged against Navitus Health Solutions has been resolved in my favor.